Collection
Anorectal Malformations & Cloacal Reconstruction
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Dilation and sending baby home is a suboptimal choice in a baby with no cardiac defect, but might be a good choice in a baby you don't want to take to the OR. — Marc Levitt, Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies · 6:03
Anatomy & Classification4 items
Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations
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Introduction: Sacral ratio (SR) is currently the only measurement to quantitatively evaluate sacral development in patients with anorectal malformations (ARM). This study proposes sacral curvature (SC) as a new indicator to qualitatively as
article · Jul 2026
Corrigendum: Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations
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[This corrects the article DOI: 10.3389/fped.2021.732524.].
article · Jul 2026
VACTERL Screening in Newborns With Anorectal Malformations - An Opportunity to Optimize Screening Practices, add Gynecologic and Spinal Conditions, and Utilize a New Acronym: VACTE(G)RLS
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Thomas O Xu, Rachel E Hanke, Kirsten Das, Melanie Bowser, Butool Hisam, Inbal Samuk, Hussein Wissanji, Erin Teeple, Allison Mayhew, John S Myseros, Andrea Badillo, Marc A Levitt, Briony K Varda, Christina Feng
Introduction: Spinal cord a
article · Jun 2025
A Genetics-First Approach Revealed Monogenic Disorders in Patients With ARM and VACTERL Anomalies
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Background: The VATER/VACTERL association (VACTERL) is defined as the non-random occurrence of the following congenital anomalies: Vertebral, Anal, Cardiac, Tracheal-Esophageal, Renal, and Limb anomalies. As no unequivocal candidate gene ha
article · Jul 2026
Prenatal & Newborn Management1 item
Fetal and Newborn Management of Cloacal Malformations
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Cloaca is a rare, complex malformation encompassing the genitourinary and anorectal tract of the female in which these tracts fail to separate in utero, resulting in a single perineal orifice. Prenatal sonography detects a few cases with fi
article · Jul 2026
Associated Anomalies2 items
The tethered spinal cord in patients with anorectal malformations
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… surgical untethering. We saw isolated cases of sensory and motor improvement after surgery … ,36,44,45 and that surgical untethering has a potential risk for causing neurological damage…
article · Jul 2026
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
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Podcast Episode · Stay Current in Pediatric Surgery · May 30, 2022 · 17m
podcast16:18 · Jul 2026
Post-discharge follow-up focuses on ensuring kidneys are well decompressed, patient is growing well, following kidney function tests, and ensuring parents manage stoma effectively. — Richard Wood, Colorectal Quiz Episode 17: Cloaca Part 1 · 24:36
Male ARM Repair2 items
The cutback revisited - The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula
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Background: The repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may l
article · Nov 2022
Colorectal Quiz Episode 1 - Low Bulbar Fistua
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Pediatric colorectal surgeons Dr. Marc Levitt and Dr. Jason Frischer discuss a case of a new born with a low anorectal malformation. Listen as they take you through the workup, diagnosis, and treatment of an ARM with an ending that you migh
video15:45 · Jul 2026
Female ARM & Cloaca5 items
Factors predicting the need for vaginal replacement at the time of primary reconstruction of a cloacal malformation
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Case series with no comparison groups.
article · Jul 2026
Colorectal Quiz Episode 29: Female ARM
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Join Dr. Kathy van Leeuwen and Dr. Cristine Velazco at Phoenix Childrenâs as they discuss the nuances of post-operative anorectal malformation management follow
podcast25:08 · Jul 2026
Colorectal Quiz Episode 18: Cloaca Part 2
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The treatment for cloacal malformations are a great example of collaboration between pediatric colorectal surgery, gynecology, and urology. In today
podcast23:10 · Jul 2026
Colorectal Quiz Episode 17: Cloaca Part 1
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The treatment for cloacal malformations are a great example of collaboration between pediatric colorectal surgery, gynecology, and urology. In today
podcast27:32 · Jul 2026
Colorectal Quiz Episode 33: Cloaca Exstrophy
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Dr. Payam Saadai joins Dr. Marc Levitt and Dr. Jason Frischer to discuss the management of cloacal exstrophy covering traditional, and newer techniques.
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video22:24 · Jul 2026
Laparoscopic Approaches2 items
Laparoscopic Approach in Anorectal Malformations: How We Do It
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Laparoscopy has a major role in the treatment of anorectal malformations (ARM) since Georgeson et al. introduced the laparoscopic assisted anorectoplasty in 2000. The majority of ARM can be repaired through a posterior sagittal incision wit
article · Jul 2026
The Role of Laparoscopy in Anorectal Malformations
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The use of laparoscopy in the minimally invasive management of anorectal malformations (ARMs) continues to evolve, although the principles guiding the anatomic surgical repair and clinical follow-up remain unchanged. In this review, we deta
article · Jul 2026
Advanced Techniques2 items
Preliminary Use of Indocyanine Green Fluorescence Angiography and Value in Predicting the Vascular Supply of Tissues Needed to Perform Cloacal, Anorectal Malformation, and Hirschsprung Reconstructions
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ICG-FA correctly identified patients who might have developed a complication from poor tissue perfusion. Employing this technology to assess rectal or neovaginal pull-throughs in cloacal reconstructions, complex HD, and ARM cases may be a v
article · Jul 2026
Colorectal Quiz: Episode 2
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In the second installment of the Colorectal quiz, Dr. Jason Frischer and Dr. Marc Levitt discuss a topic of debate - when is the right time to redo an anorectop
podcast18:15 · Jul 2026
Perineal fistula in females is probably the most confounding diagnosis in pediatric colorectal surgery, with many patients either being missed or overdiagnosed. — Marc Levitt, Anorectal Malformations Complications · 7:28
Global Bowel Management Strategies2 items
Global Strategies for Postoperative Care and Bowel Management in Patients With Anorectal Malformations: Varied Practices and Barriers
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Global Strategies for Postoperative Care and Bowel Management in Patients With Anorectal Malformations: Varied Practices and Barriers - PubMed Clipboard, Search History, and several other advanced features are temporarily unavailable. Skip
article · Jul 2026
APSP Online Webinar | Marc Levitt & team | Bowel Management Program for Fecal incontinence
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Association of Pediatric Surgeons of Pakistan (APSP) Online Webinar
Speakers: Marc Levitt, Katherine Worst, Julie Margaret
(Children's National Hospital, Washington DC)
Topic: Bowel Management Program for Fecal incontinence
video1:10:34 · Jul 2026
Complications & Reoperations1 item
Anorectal Malformations Complications
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In this episode, Dr. Marc Levitt from Nationwide Childrenâs Hospital discusses complications of anorectal malformations. This episode is brought to you by the C
podcast48:08 · Jul 2026
Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning — Jason Frischer, The Colorectal Quiz: Episode 1 · 5:05
Colorectal Quiz: Episode 40
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In this insightful podcast, Drs. Marc Levitt, Jason Frischer, and Chris Westgarth-Taylor discuss the challenging anatomy and surgical strategies for complex fem
podcast18:43 · Jul 2026
The Colorectal Quiz: Episode 1
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Pediatric colorectal surgeons Dr. Marc Levitt and Dr. Jason Frischer discuss a case of a new born with a low anorectal malformation. Listen as they take you thr
podcast15:45 · Jul 2026
Featured picks for families are being prepared — the summaries above are written for you.
Expert statements from the recordings in this collection.
Anorectal Malformations Complications
Perineal fistulas in males are commonly missed in the newborn period because the baby passes meconium through the small fistulous opening, and no one notices the abnormal anal anatomy. These patients typically present in the first year of life with severe constipation.
Marc Levitt2:55
By the time a missed perineal fistula is diagnosed, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa.
Marc Levitt3:43
The current standard is to check temperature on the forehead or in the ear rather than rectally, so if you don't look at the anus, you might not know there is a malformation.
Marc Levitt4:03
Relocating a perineal fistula into the sphincters does not completely fix the constipation, though it improves the anatomy by making the hole adequately sized and lined by mucosa.
Marc Levitt4:53
Patients with uncorrected perineal fistulas can have some semblance of continence with formed stool, but with loose stool or athletic activity they will soil because they cannot completely close the anteriorly located hole when squeezing their sphincters.
Marc Levitt5:23
A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15.
Marc Levitt6:05
A bucket handle (a lifted skin tag that you can pass a probe underneath) is consistent with a perineal fistula even if you cannot see the fistula itself.
Marc Levitt6:41
Perineal fistula in females is probably the most confounding diagnosis in pediatric colorectal surgery, with many patients either being missed or overdiagnosed.
Diagnostic criteria for perineal fistula in females: inadequate perineal body (hole too close to vagina), inadequate hole size, and hole not centered in the sphincter.
Marc Levitt7:50
If the anal opening in a female is adequate size and centered in the sphincter, even if it appears slightly anterior with a short perineal body, that patient does not need surgery. The perineal body will lengthen with growth.
Marc Levitt8:25
An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000) for intraoperative sphincter mapping.
Marc Levitt10:50
The vast majority of male ARM patients have a rectourethral fistula. It is important not to approach these primarily because you don't know where the rectum is—it could be at bladder neck, prostatic, or bulbar level.
Marc Levitt12:38
If you open posterior sagittal looking for a rectourethral fistula without knowing the location, you will find something midline, white, and shiny that might be the urinary tract, not the rectum.
Marc Levitt13:20
Cloacas can be missed in the newborn period. Dr. Levitt saw a six-month-old who presented with constipation and was found to have an undiagnosed cloaca with no hint of an anal opening.
Marc Levitt14:04
Ambiguous genitalia (clitoromegaly from endocrine stimulation) presents with a urogenital sinus but a completely normal anus. This is different from a cloaca, which has no anus and no endocrine problem.
Marc Levitt15:49
The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through by the location of the colostomy or mucous fistula.
Marc Levitt16:44
Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections.
Marc Levitt17:20
Transverse colostomies are problematic because they can prolapse, and if there is a large rectourethral fistula, the left colon absorbs all the urine (which doesn't come out the mucous fistula), causing acidosis.
Marc Levitt17:50
Dr. Levitt's preference is a very proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for the pull-through. He makes the mucous fistula very tiny and flat.
Marc Levitt18:35
Prolapse is related to where in the colon you choose to do the colostomy. Mid-transverse: both sides can prolapse. Hepatic flexure: only distal can prolapse. Proximal sigmoid: only distal (mucous fistula) can prolapse because left colon is fixed to retroperitoneum.
Marc Levitt19:58
Dr. Levitt marks the anoplasty location by drawing a circle around the pinkish ellipse where it stimulates on the skin surface BEFORE making the incision, to avoid getting lost when looking at jumping muscles from the stimulator.
Marc Levitt21:10
Really good surgeons have put anuses in crazy places because they don't have a sense of what's the center once everything is disrupted and open.
Marc Levitt22:36
The distal colostogram is an absolutely vital study. Many mistakes are made because of a poorly done study and misinterpretation.
Marc Levitt23:29
The basic questions the distal colostogram must answer: Where is the rectum? How low is it? Is it reachable posterior sagittally or better approached laparoscopically? What is its relationship to the urinary tract?
Marc Levitt23:55
The common colostogram mistake is not giving enough contrast and pressure into the distal segment, giving a false impression that the rectum is high or that there is no fistula.
Marc Levitt24:30
If you see a straight line flattening of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. You need to overcome the PC line (the sphincters compressing the distal rectum) to see the bulging rectum and fistula.
Marc Levitt25:00
Fistula classification: if the fistula is at the urethral 'elbow' or below, it's bulbar. Above the elbow is prostatic. At the bladder neck is bladder neck fistula.
Marc Levitt25:55
If the rectum is bulbous, it might be reachable posterior sagittally and hard to do laparoscopically because of the girth. If it's tapered, you're better off laparoscopically.
Marc Levitt25:55
If you don't know where the rectum is and open posterior sagittal, you will find a whitish, shiny structure and may think it's the rectum. Often it's the bladder neck.
Marc Levitt26:52
You avoid bladder neck injury by knowing exactly where the rectum is from a properly done distal colostogram. When you open posterior sagittal, you know the rectum is right under the coccyx (prostatic) or distal to the coccyx (bulbar), or it isn't posterior sagittal at all (bladder neck—do laparoscopy).
Marc Levitt27:30